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Home
Location
General Enquiries
Staff Page
Photos of El Corazon
Reservations
Menus
What's On
Contact Us
Wall of Pain
NEW YEARS EVE BOOKINGS
Tequila Selection
Cabo Wabo
Casa Noble
Don Julio
Gran Centenario
Herradura
Hussong's
Jose Cuervo
Kah
Milagro
Partida
Patron
Porfidio
Sauza
Notification of Illness, Injury, Exposure & Near Miss Form
In the event of something untoward happening at work (or directly related with work) to a member of staff or a customer (either illness, accident, exposure or a near miss), we are required by law to keep a record of the incident and, in more serious cases involving a threat to life or serious injury, report directly to the regulatory authorities (Safe Work Australia being a first point of contact).
*
Indicates required field
Name of attending supervisor completing this form
*
First
Last
Date dd/mm/yyyy
*
Injured affected person
*
Employee
Guest
Other
Incident
*
Injury
Illlness
Exposure
Near miss
Treatment or ambulance required
*
Yes
No
Witness 1
*
Witness 2
*
Witness 3
*
Name of affected party
*
First
Last
Phone Number
*
Address - line 1
*
Address - line 2
*
State
*
Post code
*
What is the injury, illness, exposure or near miss?
*
Describe how and where the injury, illness, exposure or near miss occurred
*
Possible preventative action including isolation of area and machinery implicated in the incident
*
Submit